Patient Care

Improving Breastfeeding Success with Skin-to-Skin Contact

February 2013Diana Austin

While growing up in Guatemala, Kristina Hung often translated for medical teams who came down from the US, which piqued her interest in health care. After coming to the United States for college, she enrolled in UCSF School of Nursing’s MEPN program, and when she did a clinical rotation in the labor and delivery department at San Francisco General Hospital (SFGH), she says, “I fell in love with working with moms and babies.”

She was still a student, doing her clinical rotation in the SFGH Birth Center and volunteering as a doula there, when Ocean Berg, then a perinatal clinical nurse specialist in the center, approached her about working on a project to increase breastfeeding success among babies born by cesarean section.

Hung jumped at the chance. The result was the early skin-to-skin (STS) after cesarean quality improvement project, which has not only improved breastfeeding rates at SFGH, but has also been recognized as a potential model for improving maternity care at hospitals across the nation.

Skin-to-Skin Benefits Babies and Mothers

According to the Centers for Disease Control and Prevention (CDC), 32.8 percent of births in the US are by cesarean, and studies have shown that breastfeeding rates are lower among babies born by cesarean compared with babies born vaginally. In 2010, the US Department of Health and Human Services’ Healthy People 2020 program set new goals for breastfeeding rates, including increasing the percentage of infants who are ever breastfed from a 2006 baseline of 74.0 to 81.9, and reducing the proportion of newborns who receive formula supplementation within the first two days of life from 24.2 percent to 14.2 percent.

Hung and Berg looked at the differences between SFGH’s population of healthy babies born via cesarean and those born vaginally. The only major variable – other than the route of birth – was the length of time cesarean babies were separated from their mothers. While early skin-to-skin contact is the standard of care for vaginally born babies, healthy babies born by cesarean at SFGH were taken to the nursery while their mothers were still in the operating room (OR) and recovery, resulting in separations that were a minimum of 90 minutes long and often longer.

When Hung researched the issue further, she found that several studies showed multiple positive effects for earlier skin-to-skin contact, including improved neurobehavioral development, better cardiovascular and temperature stabilization, higher maternal satisfaction and improved breastfeeding behavior.

“We weren’t going to change the cesarean rate, but the separation was something we could change,” says Hung. So she and Berg developed, coordinated and assessed a new program at SFGH: the early STS quality improvement project, in which healthy babies are placed skin-to-skin with their mothers immediately after cesarean birth, allowing the infant to initiate breastfeeding sooner.

Implementing Skin-to-Skin in the OR

Implementing the project was a multidisciplinary effort and required buy-in from the entire Birth Center team – nurses, obstetricians, pediatricians and anesthesiologists. During the planning stage, Hung and Berg interviewed stakeholders, created a flowchart to identify roles and processes, and conducted in-service education for staff.

Some were skeptical at first, says Hung. “The primary concern was safety. For example, some people were concerned about the baby moving and inadvertently contaminating the surgical wound.” To address that issue, the nursery charge nurse (who is in the OR for every cesarean section) was assigned to stay with the baby throughout the STS period, preparing the mother to receive the baby, ensuring the baby was properly positioned on the mother’s body and monitoring the process.

Hung and Berg piloted the project with several planned cesarean cases, and after an initial evaluation and some adjustments, they expanded the project to include all cesarean births in which the baby was deemed eligible after an initial assessment.

Evaluating the Results

The project was a hit with patients, but Hung and Berg wanted to know if it affected outcomes, so they collected data on all healthy infants born by cesarean at the Birth Center over a period of nine months. They looked first at the number of babies receiving early STS contact. During the initial three-month implementation period, the rate of babies receiving STS contact with mothers within the first 90 minutes after birth increased from 20 percent to 68 percent. After nine months, 60 percent of eligible babies received STS contact immediately in the OR, and 70 percent received it within 90 minutes after birth.

Next, Hung and Berg assessed whether the project had any impact on breastfeeding. Babies who received STS contact within 90 minutes scored better on LATCH assessments of breastfeeding success compared with infants who didn’t. They also found that babies who had immediate STS contact after cesarean birth had lower rates of formula supplementation in the hospital than those who had delayed contact.

Ongoing Impact

The program continues at the SFGH Birth Center, but its impact reaches beyond San Francisco. After the data were published in the September/October 2011 issue of MCN: The American Journal of Maternal/Child Nursing, Childbirth Connection, one of the oldest nonprofits dedicated to improving maternity care in the US, identified the early STS project as an example of a strategy with the potential to transform maternity care. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) plans to include information about the STS project in an upcoming book on perinatal nursing.

Over the past decade, researchers and clinicians have begun to understand and quantify the benefits of early STS contact, but it isn’t yet consistently implemented. Hung hopes that early STS for babies born by cesarean becomes standard practice: “It’s always about continually looking at our practices and moving forward.”